Provider Demographics
NPI:1033307863
Name:MARTINEZ, RICARDO (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 WINFIELD RD FL 4
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4025
Mailing Address - Country:US
Mailing Address - Phone:331-221-6377
Mailing Address - Fax:331-221-2357
Practice Address - Street 1:303 W LAKE ST STE 200
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-2500
Practice Address - Country:US
Practice Address - Phone:331-221-9001
Practice Address - Fax:331-221-3971
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036087720207Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08143606OtherMEDICARE RR
IL036087720Medicaid
ILK45726Medicare PIN
ILF77600Medicare UPIN